(Select one of the available choices or enter a different value.)Question - Required -How did you learn about Devereux Florida? Click this to indicate that you will select an existing value. Tab to next input."How did you learn about Devereux Florida?How did you learn about Devereux Florida? Click this to indicate that you will enter a new value. Tab to next input."How did you learn about Devereux Florida? Provide your answer here

3.

Your relationship to person requiring services:

(Select one of the available choices or enter a different value.)Question - Not Required -Your relationship to person requiring services: Click this to indicate that you will select an existing value. Tab to next input."Your relationship to person requiring services:Your relationship to person requiring services: Click this to indicate that you will enter a new value. Tab to next input."Your relationship to person requiring services: Provide your answer here

4.

Question - Not Required -
I would like information about the following
Devereux Florida Services:

Community Residential Program

Community Counseling Services

Developmental Disabilities Program

Devereux Kids

Therapeutic Foster Care Program

Volunteer Opportunities

5.

Question - Not Required -
I'm also interested in:

Devereux Kids

Therapeutic Foster Care Updates

Florida eNewsletter

Florida Events

About person requiring services

6.

Question - Not Required -
Age of person requiring services:

7.

Question - Not Required -
IQ of individual needing treatment:

8.

Question - Not Required -
Has the person been evaluated by a mental health
professional?

9.

What is the diagnosis?

(Select one of the available choices or enter a different value.)Question - Not Required -What is the diagnosis? Click this to indicate that you will select an existing value. Tab to next input."What is the diagnosis?What is the diagnosis? Click this to indicate that you will enter a new value. Tab to next input."What is the diagnosis? Provide your answer here

10.

Other behavior being exhibited:

(Select one of the available choices or enter a different value.)Question - Not Required -Other behavior being exhibited: Click this to indicate that you will select an existing value. Tab to next input."Other behavior being exhibited:Other behavior being exhibited: Click this to indicate that you will enter a new value. Tab to next input."Other behavior being exhibited: Provide your answer here